Venous gangrene of the upper extremity

Gangrene of the hand associated with acute upper extremity venous insufficiency has been seen in four limbs in three patients treated at Vanderbilt University Medical Center. All three patients had life-threatening illnesses associated with diminished tissue perfusion, hypercoagulability, and venous injury. One patient progressed to above-elbow amputation, but venous thrombectomy in one limb and thrombolytic therapy in two others were successful in preventing major tissue loss. All three patients eventually died from their underlying illness. Thirteen previously reported patients with "venous gangrene" of the upper extremity have been analyzed. An underlying life-threatening illness was present in the majority of these patients (7/13, 54%) and, like the Vanderbilt series, amputations were frequent (7/13, 54%) and mortality (5/13, 38%) was high. This unusual form of ischemia appears to be produced by permutations of global circulatory stasis, subclavian or axillary vein occlusion, and peripheral venous thrombosis. Early, aggressive restoration of adequate cardiac output and thrombectomy and/or thrombolytic therapy may provide the best chance for tissue salvage and survival in this group of patients.

Renal artery dissection

Renal artery dissections are stenotic or occlusive lesions most often observed in hypertensive patients with underlying atherosclerosis or fibromuscular disease. Acute dissections may present spontaneously, as a complication of diagnostic or therapeutic angiography or as an agonal event associated with overwhelming systemic illness. Chronic dissections may produce renovascular hypertension or be entirely asymptomatic. Fourteen renal artery dissections have been encountered in nine patients treated at Vanderbilt University Medical Center during the past decade. Eleven dissections have been found in seven patients with renovascular hypertension. Seven of these dissections were chronic (six functional, one silent) and four acute (two spontaneous, two secondary to angiography). Three agonal dissections were found in two additional patients postmortem: one at autopsy and bilateral dissections found at the time of cadaveric donor nephrectomy. Ten bypass procedures, including five complex branch reconstructions of which three were performed ex vivo, have been performed with 100% immediate patency and maintenance or improvement of renal function. Long-term follow-up of these patients has shown sustained patency of the reconstructed renal arteries, excellent blood pressure control, and normal renal function in all. Nephrectomy has not been required and there have been no associated deaths. Seventy-seven additional renal artery dissections in 72 patients collected from previous reports have been analyzed. Patient survival (55/72, 76.4%) and preservation of the involved kidney in surviving patients (26/55, 47.3%) were low in these earlier series. In addition, renal failure was associated with 59% of the deaths. The lethality of renal artery dissections and the ease and success of revascularization, which preserves renal function and ameliorates associated renovascular hypertension, emphasize the need for an aggressive approach to the recognition and treatment of this entity. Therapy should be directed toward arterial reconstructions and the preservation of functioning renal tissue.

Suprarenal vena caval occlusion. Principles of operative management

Retrohepatic occlusion of the inferior vena cava caused by tumor complicates complete resection and not infrequently is associated with life-threatening symptoms that accelerate the lethality of the underlying malignant process. This report summarizes our experience with caval thrombectomy and reconstruction that allowed complete removal of all gross tumor in seven patients with malignant occlusion of the retrohepatic inferior vena cava. Included in this group are five patients with renal cell carcinoma and extension of tumor into the retrohepatic vena cava. Three of these patients had extension of tumor thrombus into the right atrium. A sixth patient had recurrent right adrenal cortical carcinoma with tumor invasion of the vena cava and occlusion to the right atrium. Associated hepatic vein occlusion and secondary Budd-Chiari syndrome also was successfully managed in this patient. The final patient with occlusion of the entire suprarenal vena cava required caval reconstruction after resection of a primary leiomyosarcoma of the retrohepatic portion of the vena cava. Careful planning of the operative procedure, adequate exposure, complete mobilization of the retrohepatic vena cava, and control of the hepatic venous effluent will allow patients with retrohepatic vena caval occlusions to be managed with safety and success.

Operative management of renovascular hypertension. Results after a follow-up of fifteen to twenty-three years

From March 1960 through January 1968, 71 patients underwent operations for renovascular hypertension at our center. There were three operative deaths in 94 procedures. Primary nephrectomy was performed in 26 patients. Attempted revascularization of 62 kidneys was successful in 46 (74%). In 13 (87%) of the 15 cases considered operative failures, the patients underwent either secondary nephrectomy (11) or repeat revascularization (two). Based on the results of the final operation, initial blood pressure response (1 to 6 months postoperatively) in the surviving patients indicated 44% cured (30 patients), 40% improved (27), and 16% unchanged (11). The sequential clinical, functional, and anatomic follow-up evaluations to time of death or to date are available in 66 of the 68 patients (97%) who survived operation and form the basis of this report. Fifteen- to 20-year arteriographic follow-up in 16 patients revealed one late neointimal anastomotic stenosis and an additional three aortic suture line false aneurysms in Dacron aortorenal grafts. During this 15- to 23-year follow-up, 71% of atherosclerotic (AS) patients and 23% of fibromuscular dysplasia (FMD) patients died. Cardiovascular (CV) morbid events occurred in 77% of AS patients and in 19% of FMD patients. The cumulative incidence of death and CV morbid events during follow-up is examined by Kaplan-Meier life tables and Cox's proportional hazards regression analysis in these respective groups to identify preoperative markers predictive of longer event-free survival in relation to blood pressure benefit by operation (for example, focal vs. diffuse AS, presence of cerebrovascular disease, ischemic heart disease, left ventricular hypertrophy seen by electrocardiography, azotemia, smoking, diabetes, and hyperlipidemia).(ABSTRACT TRUNCATED AT 250 WORDS)

Antagonist of phorbol ester receptor-mediated chemotaxis in mouse peritoneal macrophages

Biologically active phorbol ester derivatives displace [3H]phorbol-12, 13-dibutyrate from thioglycollate-elicited mouse peritoneal macrophages in a time-, temperature-, and concentration-dependent manner. Scatchard analysis revealed an apparent Kd of 54.1 nM and 8.0 X 10(5) sites/cell, indicating that these macrophages possess saturable, high-affinity phorbol ester-binding sites. These derivatives also act as chemoattractants for the macrophage at equivalent concentrations. A notable exception to this pattern is phorbol-12,13-diacetate. Phorbol-12,13-diacetate inhibits specific binding of [3H]phorbol-12,13-dibutyrate (concentration required for a 50% inhibition of the maximum specific binding of [3H]phorbol-12,13-dibutyrate, 2.6 microM) and chemotaxis to phorbol-12-myristate, 13-acetate (concentration required for a 50% inhibition of the maximum chemotactic response, 0.39 microM) while exhibiting no activity as a chemoattractant at concentrations up to 10(-5) M. The data indicate that phorbol-12,13-diacetate may be an antagonist for receptor-mediated chemotaxis to phorbol-12-myristate, 13-acetate in the macrophage.

Calcium modulation of phorbol ester-induced alterations in murine macrophage morphology

The phorbol ester tumor promoter phorbol-12-myristate-13-acetate (PMA) induced mouse resident peritoneal macrophage spreading in an in vitro system in a time- and dose-dependent manner; this process was modified by agents which alter intracellular calcium metabolism. After a 35-min incubation with PMA, 50% of the macrophages were spread (as classified by at least a 2-fold increase in cell surface area). Also at 35 min, the median effective concentration for PMA induction of spreading was 1.6 ng/ml. The intracellular calcium antagonist 8-(N,N-diethylamino)octyl-3,4,5-trimethoxybenzoate inhibited PMA-induced cell spreading with a one-half maximal inhibitory concentration of 8.0 microM. The calcium ionophore A23187 enhanced PMA-induced spreading by 30% at 0.1 to 10 nM. The histological dye ruthenium red, which purportedly increases intracellular calcium by displacing membrane-bound calcium stores, enhanced PMA-induced spreading up to 75% at 1.0 pM. The cationic chelator ethyleneglycolbis(beta-aminoethylether)-N,N-tetraacetic acid (1.8 and 3.6 mM) had no effect on PMA-induced spreading. Thus, PMA-induced spreading was independent of extracellular calcium but was modulated by agents altering intracellular calcium metabolism. Microfilament formation, a proposed mechanism of cell spreading, also depends on intracellular calcium availability. The microfilament inhibitor cytochalasin B inhibited PMA-induced spreading with a one-half maximal inhibitory concentration of 1 microM. Future experiments should investigate the hypothesis that calcium availability to the cytoskeletal elements regulates the morphological effects of PMA on macrophages.

Activity of two polyene and two imidazole antimicrobics on Candida albicans in human fibrin clots

The vegetations of infective fungal endocarditis were simulated by preparing human fibrin clots containing 10(5) CFU of Candida albicans per clot. Clots were incubated in human serum without drugs (controls) or with equimolar concentrations (2.5 to 20 nmol/ml) of four antifungal antimicrobics: AMB and miconazole (both colloidal suspensions) and DAB and KET (both molecularly dispersed). Over a period of 4 days of incubation, clots were resuspended in freshly prepared serum-antimicrobic every 12 hr. Cohorts of control and drug-exposed clots were cultured quantitatively at 24 hr intervals. Neither imidazole at any concentration tested prevented growth of C. albicans to an extent that was significantly different from growth in the control clots. Both polyenes reduced the CFU/clot, with AMB significantly more active than DAB.

Histoplasma infection of abdominal aortic aneurysms

Fungal endarteritis resulting from progressive disseminated histoplasmosis may cause arterial aneurysms, or lead to infection of pre-existing aneurysms. Three patients with Histoplasma capsulatum infections of abdominal aortic aneurysms are reported. All had previous disseminated histoplasmosis and atherosclerotic peripheral vascular disease. All were considered cured of systemic infection when their aneurysms were discovered. Atherosclerotic vascular lesions may become infected during the course of systemic fungal disease and may serve as a haven for viable organisms in patients whose dissemination recurs despite seemingly adequate antifungal therapy. In treating these patients, resection of all infected arterial tissue, revascularization through uninfected tissues, and long-term antimicrobial therapy are recommended.

The role of calcium in macrophage chemotaxis to the phorbol ester tumor promoter TPA

The significance of the macrophage in the inflammatory response that occurs concurrently with phorbol ester induced tumor promotion has not yet been determined. Biologically active phorbol ester tumor promoters modify several functional responses of macrophages including chemotaxis, cytotoxicity, secretion and prostaglandin synthesis and release. The present study examines calcium metabolism as a possible underlying biochemical mechanism through which 12-0-tetradecanoyl-phorbol-13-acetate (TPA) exerts its effects on macrophage chemotaxis. The chemotaxis of mouse resident peritoneal macrophages was evaluated in the presence of pharmacological agents known to alter cellular calcium metabolism. The calcium ionophore A23187 in microM concentrations enhanced macrophage chemotaxis to TPA by approximately 41%. This enhancement was dependent on the presence of extracellular calcium. TPA-induced chemotaxis was also enhanced by the histological dye ruthenium red (RR), an agent known to modify mitochondrial calcium fluxes and calcium-dependent neuronal transmission. Ruthenium red (0.1 and 1.0 microM) produced a maximal stimulation of macrophage chemotaxis to TPA of approximately 62%. An intracellular calcium antagonist, 8-(N,N-diethylamino) octyl 3,4,5-trimethoxybenzoate hydrochloride (TMB-8) inhibited macrophage chemotaxis to TPA in a dose related fashion (1.0 to 100 microM). Varying extracellular calcium concentrations (0-3.6 mM) had no effect on macrophage chemotaxis in response to TPA. In drug combination studies neither A23187 nor RR was able to overcome the inhibitory effects of TMB-8 on macrophage chemotaxis to TPA. These results indicate that intracellular calcium metabolism may be playing a significant role in modulating TPA's effect on macrophage chemotaxis, while extracellular calcium may be of little import. A possible mode of TPA's effect on the macrophage via mobilization of calcium from cellular storage sites is discussed.

Increasing participation and improving the quality of discussions in seventh-grade social studies classes

An experiment was conducted to evaluate procedures to improve classroom discussions in seventh-grade social studies classes. An increased number of students participated in discussions when rules were stated for discussions, students were praised for their contributions, the teacher restated or paraphrased students' contributions aloud or on the blackboard, the teacher planned an outline of discussion questions, student contributions to discussions were recorded and were used to determine part of the students' grades for the class, and discussion grades were publicly posted.The second part of the study focused on procedures designed to improve quality of classroom discussions. Students were taught to participate in discussions by providing reasons for their statements, comparisons between different points, or examples supporting their statements. As each type of contribution was taught, recorded, and counted toward part of the students' classroom grades, each type of contribution increased. Ratings of discussions by outside judges consisting of junior high school teachers, junior high school students, and persons experienced in conducting discussions, indicated that the training increased the overall quality of the discussions. Use of the quality training procedures, however, resulted in decreased levels of overall participation in discussion, a decrease that was reversed by the use of a group contingency for participation. Finally, the discussions after training seemed to be preferred by both the teacher and the students.

Obturator foramen grafts: the preferable alternate route?

Although the femoral canal is the standard entrance route for vascular grafts to the lower extremity, several situations may arise that preclude the use of this route. In these circumstances an alternate pathway for revascularization is required. Experience in our center with the use of obturator foramen grafts for revascularization of nine limbs in eight patients is reported and underscores the value of this pathway as an alternative route for limb revascularization. The obturator foramen was employed to circumvent an infected arterial prosthesis at the groin level in seven patients (eight limbs) from 12 days to 4.5 years after the initial vascular procedure. The organisms responsible for graft infection included Staphylococcus aureus, Enterobacter cloacae, and Bacteroides fragilis. The final patient required iliac to superficial femoral artery bypass via the obturator foramen to manage occlusion and autolysis of the femoral artery by a mycotic embolus containing beta-hemolytic Streptococcus. Graft material used for these remedial procedures, included saphenous vein (three), Gore-Tex (three), and Dacron (three). Revascularization was satisfactory in each case. Each groin infection healed. Two patients died of unrelated causes at 1.5 and 5 months after operation. The seven remaining grafts at risk (six patients) remained patent 12 months in each case. Four grafts were doing well at 18, 36, 50, and 52 months. Three grafts failed at 13, 19, and 28 months; one was revised successfully, one was re-done and failed again. Obturator foramen bypass grafting provides satisfactory and durable revascularization when an alternate route to the lower extremity is required.

The strength of microvascular anastomoses--an experimental evaluation in rats

To determine the longitudinal strength of microvascular anastomoses during early healing, the left femoral arteries of 56 rats were divided and anastomosed with six interrupted sutures of 10-0 nylon. The right femoral arteries served as unoperated controls. The vessels were then harvested immediately, or 3, 7, 14, 21, 28, or 120-150 days after surgery. The cross-sectional surface area was measured and the force required to pull the vessels apart (burst strength) was determined with a tensiometer. Fifty-four of the 56 anastomosed vessels were patent at the time of harvest. All of the operated vessels ruptured at the site of anastomosis when the sutures pulled through the vessel wall. The mean burst strength of the anastomosed vessels was 44% of the contralateral unoperated controls immediately after surgery and did not significantly increase for four to five months. It was concluded that early mobilization of replanted parts is not limited by the strength of microarterial anastomoses.

Renovascular hypertension: anatomic and renal function changes during drug therapy

Serial renal function studies were performed on 41 patients wtih renovascular hypertension (RVH) secondary to atherosclerotic renal artery disease who had been randomly selected for nonoperative management. In 19 patients, serum creatinine levels increased between 25% and 120%. The glomerular filtration rates dropped between 25% and 50% in 12 patients. Fourteen patients (37%) lost more than 10% of renal length. In four patients (12%), a significant stenosis progressed to total occlusion. Seventeen patients (41%) had deterioration of renal function or loss of renal size that led to operation. One patient required removal of a previously reconstructible kidney. Of the 17 patients with deterioration, 15 had acceptable blood pressure (BP) control during the period of nonoperative observation. Progressive deterioration of renal function in nonoperatively treated patients with atherosclerotic renal artery stenosis and RVH is common, and occurs even in the presence of BP control with drugs.

Unaltered lymphocyte beta-adrenoceptor responsiveness in hyperthyroidism and hypothyroidism

Beta adrenoceptor sensitivity may be altered in thyrotoxicosis and myxedema. We therefore studied beta-adrenoceptor responses of peripheral blood lymphocytes to stimulation with 10(-9) to 10(-6) M (-)-isoproterenol from patients before and after treatment of myxedema and thyrotoxicosis as well as in patients without thyroid disease. There were six patients in each group. Lymphocyte basal cyclic adenosine monophosphate (cAMP) concentrations were higher in untreated thyrotoxicosis (4.94 +/- 0.46 pmole/10(6) cells) than in controls (3.47 +/- 0.42 pmole/10(6) cells, p less than 0.05) and in untreated myxedema (3.11 +/- 0.50 pmole/10(6) cells, p less than 0.025). The full isoproterenol dose-response curves were similar in all groups. Calculated maximum velocity (Vmax) showed an approximate increase in cAMP of 14.5 pmole/10(6) cells. Isoproterenol concentrations at half-maximum velocity (EC50) were approximately 10(-8) M. It is concluded that lymphocyte beta 2-adrenoceptor responses are not altered in hypothyroidism and hyperthyroidism.

DNA nucleotidylexotransferase of normal persons and leukemic patients

We describe a relatively simple and rapid assay for DNA nucleotidylexotransferase (EC 2.7.7.31) activity in normal lymphocytes and leukemic cells from blood and (or) bone marrow of patients with various types of leukemia. We followed the method of Beutler and Kuhl (Am. J. Clin. Pathol. 70: 733, 1978) but separated the product of the reaction by precipitation on filter-paper disks instead of by centrifugation. Normal lymphocytes had a mean activity of 13.5 (SD = 9.21; range 3 to 35) pU/10(8) cells. Leukemic cells from the peripheral blood of patients with acute myelogenous leukemia had a mean activity slightly greater than normal (48 pU/10(8) cells); those from patients with acute lymphoblastic leukemia had a mean activity of 863 pU/10(8) cells, or 62-fold the normal mean. Similarly, cells from patients with chronic myelogenous leukemia in acute phase had a normal activity when the cell proliferation was myelogenous, but much higher activities when the cell proliferation was lymphoblastic. Cells from patients with chronic lymphocytic leukemia had normal activity. In leukemic patients, approximately similar results were obtained with cells isolated from bone marrow.

DNA nucleotidylexotransferase of normal persons and leukemic patients

We describe a relatively simple and rapid assay for DNA nucleotidylexotransferase (EC 2.7.7.31) activity in normal lymphocytes and leukemic cells from blood and (or) bone marrow of patients with various types of leukemia. We followed the method of Beutler and Kuhl (Am. J. Clin. Pathol. 70: 733, 1978) but separated the product of the reaction by precipitation on filter-paper disks instead of by centrifugation. Normal lymphocytes had a mean activity of 13.5 (SD = 9.21; range 3 to 35) pU/10(8) cells. Leukemic cells from the peripheral blood of patients with acute myelogenous leukemia had a mean activity slightly greater than normal (48 pU/10(8) cells); those from patients with acute lymphoblastic leukemia had a mean activity of 863 pU/10(8) cells, or 62-fold the normal mean. Similarly, cells from patients with chronic myelogenous leukemia in acute phase had a normal activity when the cell proliferation was myelogenous, but much higher activities when the cell proliferation was lymphoblastic. Cells from patients with chronic lymphocytic leukemia had normal activity. In leukemic patients, approximately similar results were obtained with cells isolated from bone marrow.

DNA nucleotidylexotransferase of normal persons and leukemic patients

We describe a relatively simple and rapid assay for DNA nucleotidylexotransferase (EC 2.7.7.31) activity in normal lymphocytes and leukemic cells from blood and (or) bone marrow of patients with various types of leukemia. We followed the method of Beutler and Kuhl (Am. J. Clin. Pathol. 70: 733, 1978) but separated the product of the reaction by precipitation on filter-paper disks instead of by centrifugation. Normal lymphocytes had a mean activity of 13.5 (SD = 9.21; range 3 to 35) pU/10(8) cells. Leukemic cells from the peripheral blood of patients with acute myelogenous leukemia had a mean activity slightly greater than normal (48 pU/10(8) cells); those from patients with acute lymphoblastic leukemia had a mean activity of 863 pU/10(8) cells, or 62-fold the normal mean. Similarly, cells from patients with chronic myelogenous leukemia in acute phase had a normal activity when the cell proliferation was myelogenous, but much higher activities when the cell proliferation was lymphoblastic. Cells from patients with chronic lymphocytic leukemia had normal activity. In leukemic patients, approximately similar results were obtained with cells isolated from bone marrow.

The penetration of gentamicin and neomycin into perilymph across the round window membrane

Many commonly employed otic drops contain aminoglycoside antibiotics that may be toxic to the inner ear. A variety of chemicals such as ionic solutions, certain anesthetics, and epinephrine have been shown to diffuse across the round window membrane into the perilymph. Twelve adult cats were studied in this experiment. The auditory bulla was exposed and solutions containing gentamicin or neomycin concentrations similar to that commonly used in otic drops were applied to the round window niche for 15 minutes and washed with saline solution. The gentamicin and neomycin concentrations in the round window niche wash and the perilymph were then assayed by a radioenzymatic method. Concentrations of both antibiotics were observed in the perilymph. Thus, the round window membrane is a route through which these ototoxins may gain access to the inner ear.

Blood transfusion and renal transplantation

Blood transfusions given to potential renal transplant recipients are beneficial to subsequent graft survival. This study has shown an association graft survival. This study has shown an association between the inhibitory activity of patients' plasma on their own non-specific lymphocyte responses to antigen and the administration of blood transfusions. Most of the inhibitory activity was related to alpha-2 macroglobulin. Alpha-2 macroglobulin was able to prolong the survival of rat cardiac allografts. Immunoregulatory activity related to the alpha globulins of plasma has been described in a wide variety of conditions (i.e. cancer, pregnancy, diabetes) and this study has shown similar activity following blood transfusions.